Provider Alert! Lorazepam Clinical Prior Authorization Update

Provider Alert!

Provider Alert! Lorazepam Clinical Prior Authorization Update

Date: June 21, 2022

Attention: All Providers

Effective Date: August 1, 2022

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

TCHP will apply updates and reprocess impacted claims as soon as possible. However, please allow up to sixty (60) business days for reprocessing. Providers are not required to appeal claims unless denied for other reasons.

Providers should direct questions to their Provider Relations Liaison or send an email inquiry to the Provider Relations Department at providerrelations@texaschildrens.org.

Call to action: Texas Children’s Health Plan (TCHP) is updating the clinical edit for Lorazepam. It will allow for coverage of Lorazepam liquid formulation for members under the age two (2) years for any indication. It will also allow for coverage of patients with a history of antineoplastic agents, chemotherapy or radiation induced nausea and vomiting.

How this impacts providers: Prior authorization criteria for Lorazepam will be the following:

  1. Is the client less than 2 years of age?

[] Yes (Go to #2)
[] No (Go to #3)

  1. Is the request for a liquid formulation of lorazepam (e.g., Lorazepam Intensol, 2mg/ml, GCN 19601)?

[] Yes (Approve – 365 days)
[] No (Go to #3)

  1. Does the client have a history of an antineoplastic agent (cancer chemotherapy treatments) in the last 365 days?

[] Yes (Approve – 365 days)
[] No (Go to #4)

  1. Does the client have a history of receiving chemotherapy or documented chemotherapy-related procedural codes in the last 365 days?

[] Yes (Approve – 365 days)
[] No (Go to #5)

  1. Does the client have a history of radiation-induced nausea and vomiting or radiation procedural codes in the last 365 days?

[] Yes (Approve – 365 days)
[] No (Go to #6)

  1. Does the client have a history of a lorazepam agent for 90 days in the last 150 days?

[] Yes (Approve – 365 days)
[] No (Go to # 7)

  1. Is the incoming request for less than or equal to (≤) 1 day supply?

[] Yes (Go to #8)
[] No (Go to #9)

  1. Is the incoming request for less than or equal to (≤) 5 units per day?

[] Yes (Approve – 1 day)
[] No (Go to #9)

  1. Does the client have a diagnosis of epilepsy in the last 730 days?

[] Yes (Approve – 365 days)
[] No (Go to #10)

  1. Does the client have a history of an anticonvulsant agent in the last 45 days?

[] Yes (Approve – 365 days)
[] No (Go to #11)

  1. Does the client have a diagnosis of muscle disorder in the last 730 days?

[] Yes (Approve – 365 days)
[] No (Go to #12)

  1. Does the client have a diagnosis of anxiety disorder in the last 730 days?

[] Yes (Go to #14)
[] No (Go to #13)

  1. Does the client have a diagnosis of drug abuse in the last 730 days?

[] Yes (Deny)
[] No (Go to #14)

  1. Is the client less than (<) 12 years of age?

[] Yes (Deny)
[] No (Go to #15)

  1. Is the client between 12 and 18 ( 12 and  18) years of age?

[] Yes (Go to #16)
[] No (Go to #19)

  1. Does the client have a diagnosis of anxiety disorder in the last 730 days?

[] Yes (Go to #17)
[] No (Go to #18)

  1. Does the client have a history of an anxiolytic agent for 60 days in the last 90 days?

[] Yes (Deny)
[] No (Approve – 60 Days)

  1. Does the client have a history of an anxiolytic agent for 30 days in the last 60 days?

[] Yes (Deny)
[] No (Approve – 30 Days)

  1. Does the client have a diagnosis of anxiety disorder in the last 730 days?

[] Yes (Go to #20)
[] No (Go to #21)

  1. Does the client have a history of an anxiolytic agent for 180 days in the last 200 days?

[] Yes (Deny)
[] No (Approve – 180 Days)

  1. Does the client have a history of an anxiolytic agent for 60 days in the last 90 days?

[] Yes (Deny)
[] No (Approve – 60 Days)

 

Drugs Requiring Prior Authorization
Label Name GCN
LORAZEPAM 0.5 MG TABLET 14160
LORAZEPAM 1 MG TABLET 14161
LORAZEPAM 2 MG TABLET 14162
LORAZEPAM 2 MG/ML VIAL 14140
LORAZEPAM INTENSOL 2 MG/ML 19601

 

Next steps for providers: Prescribers can find updated prior authorization for Lorazepam on the Navitus page. Prescribers should share this update with their staff.

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.

For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.

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